ACOs Should Run for the Exits and Into Medicare Advantage
CMS recently released results from the Medicare Pioneer Accountable Care Organization (ACO) Program and the Medicare Shared Savings Program (MSSP). Once again the results are a mixed bag: quality is up, but the ROI for most participants is a joke. The update should have the most sophisticated demo sites running for the exits and into Medicare Advantage — but they need to move fast with the holidays and a February filing deadline for 2017 looming.
Pioneer ACO Program
CMS initially selected 32 health systems to participate in the program. It's down to 19 today. For the year 2014, 622,000 beneficiaries participated. Findings:
- Pioneer ACOs generated total savings of $120 million in 2014, a 24% increase from 2013 ($96 million) and $88 million in Year 1 savings.
- Eleven health systems generated gross savings beyond the minimum goal and received performance payments totalling $82 million. That's a pittance for what's been invested to participate. Of the 11 companies, a few reported notable savings:
- Banner Health in Arizona generated roughly $18.7 million in savings
- Partners Healthcare in Massachusetts generated roughly $13.2 million in savings, with around 70,000 beneficiaries participating.
- Beth Israel in Massachusetts lowered costs by 3.7% and generated roughly $9.8 million in savings.
- OSF Healthcare System in Illinois lowered costs by 3.0%
- Michigan Pioneer ACO in Michigan lowered costs by 6.3%
- Monarch Healthcare in California lowered costs 4.0%
Three Pioneers incurred the nightmare scenario of a giveback payment to CMS in 2014, including Beacon Health in Maine ($2.9 million), Dartmouth-Hitchcock in New Hampshire ($3.6 million), and Franciscan Alliance in Indiana ($2.5 million). All had to inform CMS of their decision to stay or exit the program by September 14. After two years of consecutive losses, Dartmouth-Hitchcock planned to exit Pioneer and apply instead for the Next Generation ACO program. It's a black eye for the system that's home to Dr. Elliott Fisher, widely considered to be the inventor of ACOs. Beacon Health is also exiting the program after facing losses for two years in a row, and will also apply for Next Generation.
Total model savings per Pioneer was $6.0 million in Year 3 (2014), up from $4.2 million per ACO in 2013 and $2.7 million per ACO in Year 1 (2012). The mean quality score among Pioneer ACOs increased to 87.2% in 2014, an improvement of 200bps from 85.2% average performance in 2013, and way ahead of 71.8% in Year 1. The Pioneers improved on 28 out of 33 quality measures. So most are delivering the quality goods, but aren't seeing much if any return for the effort.
Medicare Shared Savings Program
In 2014, there were 333 participants in the Medicare Shared Savings Program, and 92 of these ACOs kept spending below their targets, up from 58 ACOs out of 114 in 2013. The victorious 1/3 earned $341 million in performance payments. Takeaways:
- $465 million of the savings generated will accrue to the Medicare Trust fund, $341 million will be returned to participants.
- 89 ACOs actually reduced health care costs compared to their benchmark, but did not qualify for shared savings because they did not meet the minimum savings threshold. So 2/3 of ACOs are winning on expense, but only half of those got paid. That's a problem.
- Veteran ACOs were more likely to generate performance payments. Twice as many ACOs that entered the program in 2012 got paid vs. freshman systems (38% vs. 19%).
Lined up alongside other innovation failures like the bundled payment and nursing home quality demonstrations, it's clear CMS's innovation agenda has been hobbled by poor design and lack of business acumen. There's never been a better time for an industry veteran like Andy Slavitt to lead the agency out of the darkness.
The clock is ticking for ACOs to make the evolutionary leap into the one "devil we know" of Medicare Advantage.
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The Medicare Advantage Value-Based Insurance Design (MA-VBID) Model Test
The Centers for Medicare & Medicaid Services (CMS) announced on September 1 a proposed demonstration that will test varying benefit designs based on health status. The overall goal is to improve clinical outcomes while reducing plan expenditures.
This demonstration is proposed for seven states: Arizona, Indiana, Iowa, Massachusetts, Oregon, Pennsylvania, and Tennessee. According to the announcement, only current Medicare Advantage organizations in good standing in those states will be allowed to participate. The demonstration is aimed at Health Maintenance Organizations (HMOs), Health Maintenance Organization Point of Service (HMO-POS) plans, and local Preferred Provider Organizations (PPOs) in order to determine how it affects beneficiaries and costs in the most common plans. Special Needs Plans (SNPs), Regional PPOs, Medicare-Medicaid Plans (MMPs), Private Fee-for-Service (PFFS) plans, Employer Group Waiver Plans (EGWPs), Health Savings Accounts, and cost plans are not eligible.
The demonstration will waive certain regulations so benefit plans can vary for enrolled members based on their diagnosis, condition, or need for a medical service. Currently, health status distinctions in providing benefits to enrolled beneficiaries are prohibited by regulations. Organizations can propose any myriad of combinations of benefits or services provided they are based on the proposed chronic conditions listed in the announcement. Most importantly, CMS notes participating organizations can initiate the demonstration with a limited benefit and can expand their benefit plans during the five-year term of the demonstration. While the benefits will be mandatory supplemental benefits, CMS proposes to prohibit marketing these benefits to non-member beneficiaries.
The CMS process begins with the submission of a Request for Application (RFA). Organizations failing to submit an RFA cannot participate in 2017 but may be allowed at a later date during the five-year demonstration period. Organizations must submit an RFA that has sufficient detail to allow CMS to determine if the benefit plan addresses targeted beneficiaries, will provide measureable results, and is appropriately structured for the demonstration.
RFAs are currently due by November 15. CMS will bind the organization to the proposed benefits in the RFA to their bid proposal for 2017. Consequently, conducting in-depth data analyses is necessary to propose a benefit plan in the RFA. This is the critical step that must begin in the very near future to meet the RFA submission date.
Is this the right opportunity for your organization? Attend our webinar to find out.
Join John Gorman, Founder and Executive Chairman at Gorman Health Group, on Tuesday, September 29 from 1-2 pm ET, as they outline the MA-VBID plan requirements, as well as what you should be doing now to prepare for January 2017.
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Health plans in the applicable states need to place emphasis on data analysis and strategic planning as well as application support. We can help - Contact us today.
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Final Rule for Medicare Prescription Drug Benefit Program Coordination Requirements
Where has the summer gone? When you get your formulary submission approval email, you breathe a sigh of relief and can relax for…a second. It's time to start planning for Part D Readiness and Benefit Administration testing so when November 15 arrives, you are well on your way to having those completed.
For Medicare Advantage plans, the heat is on for point of sale Part B versus Part D determinations. The regulation set to take effect on January 1, 2016, follows:
Final Rule, MA, PDP, CMS-4159-F2
MA-PD Coordination Requirements for Drugs Covered under Parts A, B, and D — The Centers for Medicare & Medicaid Services (CMS) acknowledges beneficiary access to needed drugs is impeded when a Medicare Advantage Prescription Drug plan (MA-PD) does not properly adjudicate claims for drugs that may be covered under Part A or B, rather than Part D, at the point of sale (POS). Thus, CMS is requiring MA-PDs to establish and maintain a process to ensure appropriate payment is assigned at the POS. If a denial under Part D is based on the existence of coverage under Parts A or B, the MA-PD plan should authorize or provide the drug under that other benefit without requiring the enrollee to make a subsequent request for coverage under that other benefit. According to the preamble of the final rule, CMS is amending 42 CFR §422.112(b)(7) to "require MA-PDs to coordinate with their network pharmacies and prescribers to improve existing processes and develop new ones in order to ensure that enrollees receive their Medicare-covered prescription medications, without delay, when they present at the network pharmacy." While CMS did not include beneficiary advocates' request to require plans to treat a POS claim transaction as a request for a coverage determination under Part D, this new rule should nonetheless improve coordination of and access to drug coverage for MA-PD enrollees.
Benefit administration testing is a relatively inexpensive insurance policy for 2016. Picture yourself on January 1 watching the adjudication system paying claims, adhering to the CMS-submitted benefit parameters, and no calls to 1-800-MEDICARE. That could be your experience with the enhanced benefit administration testing expertise GHG employs. We use a set of approximately 100 specific parameters against which to test approximately 1,000 claims. When we find issues, we work with you and your Pharmacy Benefit Manager (PBM) to get them resolved BEFORE live claims start rolling in on January 1. The countdown is on—123 days until January 1!
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The CMS Fall Conference: 4 Ways to Solve the Preparedness Problem
The Centers for Medicare & Medicaid Services (CMS) held their Fall Conference and Webcast on September 10 in Baltimore. The presentations and videos from the event are found on the Compliance Training, Education & Outreach site here. CMS covered various aspects of the Medicare Advantage Prescription Drug (MA-PD) program, but here I've focused on four lessons I heard loud and clear: work with CMS, prepare ahead of time, seek continuous improvement, and don't wait until the last minute.
Linda Anders from CMS hosted two Aetna representatives who discussed lessons learned in beneficiary and pharmacy outreach stemming from strategic network changes taking place over 2014 to 2015. They had developed a communication strategy but soon understood a lack of clarity and misinformation caused significant beneficiary and pharmacy confusion. Ms. Anders stressed there is much to be learned from Aetna for any plan contemplating changes to their program. Aetna recognized their Part D network configuration was "generally consistent" with CMS requirements. It is recommended any plan contemplating program changes not tested in the industry work closely with CMS on these initiatives.
Gregory Woods gave valuable information regarding the Value-Based Insurance Design (VBID) Model Test. Things will move quickly for the VBID model. While they are beginning this test for 1/1/2017 effectives, the Request for Application (RFA) responses will be due sometime this November or December. This is new, so Compliance and Product teams, prepare yourself for a new onslaught of questions from Clinical and Actuarial, because they are coming.
As a lead-in to a presentation from MAXIMUS Federal Services, CMS confirmed they are working with a small number of plans on point of sale rejections. They hope to share more information about that in the 2017 call letter. Some helpful reminders were then provided regarding appeals going to MAXIMUS. Make sure your organization is referring to the most updated process manuals provided by MAXIMUS for Part C and Part D appeals. Additionally, there is a significant amount of appeals data dating back to 1997 showing your plan's percentage of upholds and overturns. Organizations can compare to other plans to benchmark or simply leverage to spark internal process improvements. Cathleen MacInnes, Project Director, also addressed the development of a submission portal for electronic upload of case info to MAXIMUS. If your organization is interested in participating, contact either her or her Part D counterpart. From an operational perspective, that should make sharing case info much easier, so long as it is secure, secure, secure.
The icing on this conference cake was the update from Jennifer Smith, Director, Division of Analysis, Policy and Strategy, Medicare Parts C and D Oversight and Enforcement Group, on 2015/2016 program audit protocol, processes, and activity. The changes she outlined are exciting — here are some, and since I've already written plenty, you can either watch the video or contact me for more details and my thoughts.
- Edits to record layouts will include not only those outlined during June's Oversight and Enforcement conference but also additional edits based on plan and auditor feedback. Extraneous fields will be gone, headers will be added to record layouts, and more clear instruction will be incorporated as to what should be included and excluded.
- Beneficiary Impact Analyses (BIAs) will not be requested at the time of the self-identified and self-disclosed issue reporting. Organizations should still anticipate a BIA request if an issue is found during an audit.
- CMS is also revising their policy on the "three strikes" for universe submission.
- The two anticipated pilot audit areas are being moved to 2016.
- Compliance Program Effectiveness (CPE) will be conducted either onsite or virtually.
"It is also important to remember the audit protocols are more like a pop-quiz than a final exam," says Charro Knight-Lilly, Senior Vice President of Client Relations. Don't lose sight of the need to comply with all requirements and testing performance through monitoring, auditing, and annual risk assessment. Ms. Smith said something that resonated with me and likely others in the industry: Don't wait until the audit notice to practice universe pulls and activities. If you do, you are behind the 8-ball.
Resources
CMS outlined areas of poor performance within the release of the Outlier Notification in August. In addition to audits and Corrective Action Plans (CAPs), this notice also referenced Compliance Letters (C and D) and Star Ratings (C and D) as areas of concern and indicators of poor performance. Both of these areas require advance planning, preparation, and coordination in order to make an impact a minimum of one full year later. Don't exhale as we head in to the 2016 Annual Election Period (AEP) — now is the time to plan strategy for 2017. Contact us to learn more.
Join John Gorman, Founder and Executive Chairman at GHG, for our upcoming webinar on MA-VBID Model plan requirements, needed strategies for data analysis and benefit development, as well as what you need to be doing now to prepare for January 2017 on Tuesday, September 29, from 1-2 pm ET. Register here
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How to Partner with Key Health Systems in your Service Area to Optimize Benefit Plan Offerings
As we anticipate additional information this week on the Centers for Medicare & Medicaid Services (CMS) network adequacy (pilot) audit, we can't help but consider how CMS' rigorous access and availability standards hamper Medicare Advantage (MA) plans' ability to be on the cutting edge of innovative network design. The Affordable Care Act, in comparison, has allowed for Marketplace plans to offer narrow networks as long as the networks have sufficient numbers and types of providers to deliver services without "unreasonable delay," leaving states to define the meaning of "unreasonable." This difference in network adequacy standards has widened the gap in plan offerings.
MA plans, after meeting network adequacy standards, are able to offer tiered benefit plans to members ensuring members are still afforded access to the larger network if not all standards are met within the smaller subset. The tiered benefit designs leave MA plans with the question of which providers would be the best partners.
In evaluating provider partners for tiered benefit designs or co-branding opportunities, health plans need to determine the attractiveness of each prospective provider by asking questions such as: Does the potential provider system have a similar philosophy? Is the provider system large enough to meet network adequacy standards in a given market area on their own, or would fill-in providers be required? How would their participation or non-participation in our network affect our market strategy? Does the provider system do anything particularly well, do they have unique services, service area, or exclusive providers, and how can those services be packaged? Would these bundled services contribute to increased revenue and/or market share?
In turn, provider systems that may be contemplating offering their own provider-sponsored health plan could be asking themselves similar questions and determining if a payor partnership would be a good option. Providers should develop a plan/partner evaluation process concurrent with developing a marketing strategy in order to find the best available partnership.
As we see the Marketplace and Medicaid proposing similar network access and availability standards as MA plans, we easily foresee a change in how these two government-sponsored programs will need to re-evaluate their network design. By beginning to monitor their networks now, Medicaid and Marketplace plans will be able to identify some of the provider network challenges MA plans have faced. As CMS moves forward with decisions on network adequacy for all government-sponsored health plans, enhanced relationships between payors and providers will be key in developing the networks needed to support competitive benefit plans.
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Gorman Health Group evaluates the design and delivery of high quality collaborative care while achieving compliance and improving revenue cycle management. Our multidisciplinary team of experts will assess the alignment of your products, your current network and your market to translate your business strategies into practical, efficient and rigorous work processes with the highest degree of compliance and accountability. Visit our website to learn more >>
From ACO-type incentives to bundled payments and contract capitation, to full professional and global capitation — where the potential is promising, we can help design and implement these arrangements. Let's get started. Contact us today
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Government Sends Stark Reminders that Insurers' Biggest Customer is Still the Regulator
Since we opened our doors 19 years ago, we've preached to health insurers to think of the government as your business partner. This week, we got several reminders that insurers' biggest customers -- Medicare, Medicaid, and ObamaCare -- are still the regulator. As business conditions improve for health plans across these business lines, government expectations are rising, and scores are about to get settled, as they always are in the second term of a Democratic administration.
We see it in enforcement activity from the Centers for Medicare & Medicaid Services (CMS). We see it in a steadily-rising bar of Star Ratings and other performance measures for health plans for all three programs, the basis of looming contract terminations. And now the White House jumps in with an aggressive schedule of risk adjustment data audits, openly seeking repayments and dropping "f" bombs: fraud, that is.
They named a great film after a moment like this: "There Will Be Blood."
You can't argue with the numbers: 2015 remains the most punitive year in Medicare Advantage history. Look at the trend:
CMS is also being much more aggressive this year with data-driven oversight and enforcement. Communications to health plans who are "outliers" in various performance measures, especially in member communications and consumer protections, began recently. A pattern we are seeing play out is CMS chasing down all clients of noncompliant pharmacy benefit managers; where poor Part D performance is seen in one plan, the agency then begins auditing that vendor's other customers, assuming they'll get the same findings.
We know that Star Ratings and expanding reporting requirements in Medicare Advantage and Part D mean the bar is rising and establishes data-driven thresholds against which health plans can be penalized and terminated beginning in 2016. CMS announced sweeping new reporting requirements for both programs this week, which inevitably get picked up in Medicaid and ObamaCare rules in following years.
And now the White House is piling on. In Washington, we talk a lot about "setting the terms of debate." Our industry has lost the debate on risk adjustment coding and has allowed anti-managed care advocates to define payers' inaccurate diagnostic coding as fraud. A just-disclosed February 2015 letter from President Obama's Budget Director to Health Secretary Sylvia Matthews Burwell stated, "While some progress has been made on this front, we believe a more aggressive strategy can be implemented to reduce the level of improper payments we are currently seeing...we must continue to explore new and innovative ways to address the problem and attack this challenge with every tool at our disposal...the government estimate of $12.2 billion in these mistakes for fiscal year 2014 remains a concern." He extended his mandate beyond Medicare Advantage to over $3 billion in questionable payments from Medicaid. This means a spike in data validation audits for payers across both programs with the threat of improper payment clawbacks and even prosecution under the False Claims Act.
There has never been a more Golden Age of opportunity for health insurers in government programs. But the threats are escalating as well, and as my politics professor told me, "99% of political wounds are self-inflicted." Plans caught up in this dragnet will have gotten plenty of warnings.
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The Part C and Part D Reporting Requirements and Supporting Regulations were posted in the PRA Listing on August 24th for review and 30-day comment. Since we are still in this window, this is a great opportunity for Compliance and Operations to review these together. Click here to review the Part C highlights that merit your attention in a blog posted by Regan Pennypacker, Senior Vice President of Compliance Solutions at Gorman Health Group (GHG).
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Potential Changes in Part C Reporting
The Part C and Part D Reporting Requirements and Supporting Regulations were posted in the PRA Listing on August 24th for review and 30-day comment. Since we are still in this window, this is a great opportunity for Compliance and Operations to review these together. To follow are Part C highlights that merit your attention.
Organization determinations/reconsiderations, Special Needs Plans care management, and enrollments/disenrollments, were updated to include additional data elements, and two new reporting sections were added: Rewards and Incentives Program and Mid-Year Network Changes.
For most data elements with a due date of February 28, the data due date was changed to a couple of different Mondays in February, and the due date for enrollment/disenrollment was changed to the last Monday in August and February. These timing changes are proposed so the reporting load would be more manageable in 2016 than it was in 2015 for the Centers for Medicare & Medicaid Services (CMS)/Health Plan Management System (HPMS), and hopefully it will be more manageable for Plan Sponsors as well.
Two new data elements for Section 6 include the reporting of dismissals for organization determinations and reconsiderations to be more aligned with Part D reporting requirements.
Special Needs Plans (SNPs) will now also report four new pieces of data:
- the enrollee initial health risk assessment (HRA) refusals,
- the annual reassessment refusals
- the HRAs where the SNP was unable to reach new enrollees, and
- the annual reassessments where the SNP was unable to reach enrollees.
Excluded from this reporting are the HRAs that were not done where no refusal is documented and the HRA simply did not happen.
A few new disenrollment data points will now be requested:
- The total number of involuntary disenrollments for failure to pay plan premium in the specified time period.
- Of the total reported in the above, the number of disenrolled individuals who submitted a timely request for reinstatement for good cause.
- Of the total reported in the above, the number of favorable good cause determinations.
- Of the total reported in the above, the number of individuals reinstated.
A new reporting section is proposed for rewards and incentives programs. Plan Sponsors who respond in the affirmative will be required to explain which health-related services and/or activities are included in the program, which rewards enrollees may earn for participation, and how the value of the reward is calculated. They will also need to describe how enrollee participation is tracked, how many enrollees are currently enrolled, and how many rewards have been awarded so far.
Not surprising, CMS' increased oversight over network adequacy is making its way into Part C reporting. The new reporting section, Mid-Year Network Changes, will provide CMS with visibility into how often Plan Sponsors undergo mid-year network changes and how many enrollees are affected by this type of change. CMS states, based on 60-day comments, CMS increased the data elements from 13 to 53. Fun! CMS also states, "Collecting this data will help to inform CMS in determining how broadly to use the new Network Management Module (NMM) in HPMS to verify that plans' networks meet CMS network adequacy standards." If you recall from CMS' 2015 Medicare Advantage Prescription Drug (MA-PD) Spring Conference & Webcast, presenters specifically addressed this module and said Medicare Advantage Organization (MAO)-initiated submissions will not be viewable or evaluated by CMS. However, the NMM also allows for CMS-initiated requests of Health Service Delivery (HSD) tables "in support of various processes," which certainly you can presume will be viewable and evaluated. I don't know about you, but if it is in HPMS, it's viewable to CMS.
For all Plan Sponsors who currently do not have mechanisms for capturing this information, we encourage you to nail down a process. Operational areas may want to get a head start on determining how this information is captured today. CMS is using data now more than ever to determine outliers and to identify candidates for program audits, both of which can lead to enforcement actions. Remember: what they are asking Plan Sponsors to report on are not new requirements — so we anticipate CMS to have little patience for those who demonstrate non-compliance with items agreed to upon initial application.
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Compliance permeates every department, and must be supported by effective tools and rigorous oversight. Learn how we can help you create early warning systems to ensure that operational inefficiencies and threats to member satisfaction are identified immediately. Visit our website to learn more >>
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Changes for 2015 Part D Reporting Announced by CMS
The Centers for Medicare & Medicaid Services (CMS) recently released an updated version of the Contract Year 2015 Part D Reporting Requirements Technical Specifications.
Sponsors are required to undergo data validation to have some of their Part D data audited annually. Each Part D Sponsor is required to provide necessary data to CMS to support payment, program integrity, program management, and quality improvement activities. Additional reporting requirements are identified in separate guidance documents throughout the year.
REPORT DELETIONS
Long-Term Care (LTC) Utilization -
One notable change for 2015 reporting is the LTC Utilization section will be suspended effective immediately because similar information can be obtained using Prescription Drug Event (PDE) data. Similarly, CMS removed the LTC Utilization reporting section which reports information about the total number of beneficiaries in LTC facilities for whom Part D drugs have been provided because it is provided elsewhere in the Plan's CMS contract.
Prompt Payment -
CMS removed Prompt Payment to Part D Sponsors and Fraud, Waste, and Abuse (FWA) reporting sections and decreased hour estimates associated with these sections because CMS determined these data are no longer necessary for monitoring through these reporting requirements.
CMS has determined the reporting of these data is no longer necessary for monitoring through FWA reporting requirements. Other methods using data validation processes have replaced the need for this reporting element. Annual Data Validation Audits, informatic analysis of PDE data, and other elements reported elsewhere meet the FWA monitoring goals of CMS.
REPORTING CHANGES
Medication Therapy Management (MTM) -
The addition of a note, reporting of Line Q, "Date(s) of Comprehensive Medicare Reviews (CMRs) with written summary in CMS standardized format," has been reduced to two CMR dates, even if more have been completed. One CMR is required if the member meets eligibility requirements. After analyzing the data, CMS concluded only two dates are needed for monitoring purposes.
CMS provided clarification to Line S, "Qualified Provider who performed the initial CMR," (Physician; Registered Nurse; Licensed Practical Nurse; Nurse Practitioner; Physician's Assistant; Local Pharmacist; LTC Consultant Pharmacist; Plan Sponsor) to provide more descriptive choices.
The Technical Specifications for Part D Reporting document can be viewed in its entirety as posted on the Health Plan Management System (HPMS) Plan Reporting site and on the external CMS website by clicking this link.
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We can help your MAPD or PDP develop and implement efficient and compliant internal operations and prepare effectively for CMS audits with professional services and unmatched compliance tools. Visit our website to learn more >>
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Teaming with Providers: Together, Everyone Achieves More
When a team works well together, the members collectively accomplish more than any of the individuals could have accomplished alone. Certainly, we have proven that adage true in healthcare, as can be seen with the success of integrated delivery systems, Independent Practice Associations (IPAs), and Accountable Care Organizations (ACOs).
As health plans continue adapting to the growing influence of clinical quality on its provider network operations, building an effective team with your providers has never been more important.
But, factor in the necessities of compensating members of the team for their role, of each team meeting its profit targets and the competing priorities faced by often short-staffed teams, it should come as no surprise many health plan staff and providers are left wondering how to make it happen. Below are our top five ways to engage your providers to influence your Star Ratings.
- Prioritization: Ensure Clinical, Risk Adjustment, Stars, Claims, and Network Operations are all collaborating and prioritizing their "asks" of the providers and working together to ensure the needs of the providers are met.
- Education, Education, Education: By arming your leaders with the education necessary to purchase the best reporting tools, they are able to develop the goals and framework necessary for the frontline staff to educate and respond to providers.
- Support ICD-10 readiness: If CMS predictions hold true, denial rates and outstanding receivables are likely to increase during the conversion. Despite testing and readiness efforts, it's entirely possible some providers may not be staffed or prepared to mitigate technology-related problems among its payers or to weather the longer-term reduced productivity of their coding staff. Before your providers can invest additional energy into our Quality priorities, they've got to keep the cash flowing.
- Focus on actionability: Health plans often provide catalogs of reports each month showing providers' numerous views of their panels and forget providers are taught evidence-based medicine and how to care for patients, not administrative functions. By telling providers to improve care, we can make them vulnerable and defensive. By collaborating to improve processes and coordination for better patient satisfaction and outcomes, we can let the providers be providers.
- Continuous measurement, re-evaluation, and reward: While we naturally monitor our outcomes and re-evaluate our processes, we sometimes forget to reward ourselves for a job well done. We can build in contractual provider incentives, but peer recognition and a "thank you" are often simple but overlooked motivators.
Questions to ask:
- Were there any surprises in your first Star Ratings Plan Preview rates?
- Are your providers effectively supporting your Star Ratings goals?
From identifying the health plan functions that require provider engagement, to interpreting Plan Preview rates and trends in order to build 4th quarter Star Ratings action plans and evaluating provider contracting strategies around a holistic approach, our team can help. Contact me directly at emartin@ghgadvisors.com .
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CMS recently notified plans of the first preview period for the 2016 initial Star Ratings data. It is critical for plans to begin evaluating their Star Ratings now to pinpoint problem areas, implement tactical actions, and identify improvement opportunities to raise their current score. Need assistance with your action plan or preparing for plan year 2016? Contact us today >>
At Gorman Health Group, we can help you decide what payment models are appropriate to your unique circumstance and support your implementation efforts. Learn more >>
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The Impact of CMS Changes on MA & FFM 2016 Agent Readiness
Preparing for the 2016 selling season means implementing a strategy that mitigates compliance risks for your organization and empowers your sales force to meet your enrollment targets. In our recent webinar regarding the impact of the Centers for Medicare & Medicaid Services (CMS) changes on Medicare Advantage (MA) and Federally-Facilitated Marketplace (FFM) 2016 Agent Readiness, I outlined key takeaways your organization needs to enforce in order to protect your health plan from compliance risks while also positioning it for sales success in 2016 and beyond.
1. MA/Part D Compliance and FWA Training for FDRs:
Beginning on January 1, 2016, every organization will need to ensure Compliance and Fraud, Waste, and Abuse (FWA) training requirements for first-tier, downstream, and related entities (FDRs) are fulfilled ONLY through CMS courses found on the Medicare Learning Network (MLN). This includes contracted Field Marketing Organizations (FMOs) and agents/brokers. This means the organization may now require these individuals to take custom training and must have mechanisms in place to accept completion of the CMS training. CMS also explicitly states plans will need to provide accurate reporting of this information.
Ways to fulfill requirement:
Note this requirement does not exempt organizations from ensuring all employees and FDRs are informed on how to report instances of fraud, waste, or abuse and other relevant information as described in Compliance Program requirements.
2. New Features for Health Insurance Marketplace Training
CMS is implementing changes to its process where vendors will be offering training. CMS has approved three vendors as "conditionally approved" (not approved until go-live in late summer 2015). GHG is a conditionally-approved vendor for Health Insurance Marketplace training. The number one takeaway from this is agents still begin and end on the CMS website. They cannot come to any vendor website to take their training; they must go directly to CMS and choose the party they would like to utilize.
Important to note:
- Vendors may use CMS' training or vendor-developed training approved by CMS.
- New! Vendor pricing varies: GHG's pricing is $29 for Individual and/or Small Business Health Options Program (SHOP), while AHIP is $125 for Individual or SHOP and $150 for both.
- Vendors offer Continuing Education (CE) units in 5 or more states (pricing varies by vendor).
For information on the requirements and process for completing Health Insurance Marketplace agent and broker registration and training for plan year 2016, please visit here.
Learn more about GHG Health Insurance Marketplace training at exchangebrokertraining.com.
3. Plan Benefit Training Is Important (but doesn't have to be long!)
The point of plan benefit training is not to communicate every detail of your benefits but to provide key information, such as:
- basic company information,
- plan types,
- service areas,
- premiums and deductibles,
- any changes from benefits last year,
- network restrictions and/or changes,
- highlights of drug benefits,
- description of value-added benefits,
- anything that makes you stand out from competitors, and
- most importantly, how and where to get more detailed information
Remember, every interaction your sales agents have with prospective enrollees should be viewed as a golden opportunity to educate the public about your organization. Ensure your staff is effectively trained to make every member touch count.
4. Licensure
CMS does not specify how or how often the organization checks licensure − just that they ensure the agent is licensed. GHG recommends the organization use primary-source verification through the state Department of Insurance (DOI) or National Insurance Producer Registry (NIPR). At a minimum, the organization should check annually and upon any expiration date. Quarterly checks are slightly more robust, and monthly checks the most rigorous.
5. OIG/GSA (Exclusion) Checks
Like compliance and FWA training, this is a compliance requirement that applies to all delegates (and employees) — not just agents. Every agent representing your plan needs to be checked against the federal exclusion lists every month. Plans need to work with their Compliance Department to ensure this requirement is met.
Whether you operate strictly in the MA market or are participating in the Health Insurance Marketplace, thorough and streamlined agent/broker training positions your plan to make the most of every opportunity and minimize compliance risks. Focus on better agents, not just more agents, to best serve your plan and your beneficiaries.
Need help? GHG's fully-automated Sales Sentinel™ can take your agents from zero to ready-to-sell in as little as one week, ensuring agents are not only trained but contracted, licensed, and appointed per CMS requirements. Sales Sentinel™ can also assist your organization with administrative onboarding functions such as form collection and writing code assignment.
If you have questions, please contact me directly at afleming@ghgadvisors.com.
Resources
Gorman Health Group is one of three conditionally approved for exchange marketplace training, is accepted by all carriers in federal exchange states and provides CE credits available in most states. To learn more visit exchangebrokertraining.com >>
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